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Although the majority of patients with Hodgkin lymphoma (HL) are cured with initial therapy, in 85–90% of early stage and 70–80% of advanced-stage disease cases, relapse remains a major problem. Autologous stem-cell transplantation (auto-HCT) after salvage chemotherapy is currently considered to be the standard of care for patients who relapse after first-line chemotherapy or for whom first-line treatment fails. The curative capacity of auto-HCT has been improving with the introduction of new drug-based salvage strategies and consolidation strategies after auto-HCT. Allogeneic stem-cell transplantation (allo-HCT) represents a reasonable treatment option for young patients who relapse or progress after auto-HCT and have chemosensitive disease at the time of transplantation. Allo-HCT is a valid treatment strategy for patients with relapse/refractory HL (r/r HL) because the results have improved over time, mainly with the safe combination of allo-HCT and new drugs. Bearing in mind that outcomes after haploidentical stem-cell transplantation (haplo-HCT) are comparable with those for matched sibling donors and matched unrelated donors, haplo-HCT is now the preferred alternative donor source for patients with r/r HL without a donor or when there is urgency to find a donor if a matched related donor is not present. The development of new drugs such as anti-CD 30 monoclonal antibodies and checkpoint inhibitors (CPI) for relapsed or refractory HL has demonstrated high response rates and durable remissions, and challenged the role and timing of HCT. The treatment of patients with HL who develop disease recurrence or progression after allo-HCT remains a real challenge and an unmet need.

Indications for autologous (auto-HCT) and allogeneic transplantation (allo-HCT) in relapsed/refractory Hodgkin lymphoma (rrHL) have been long established. The expectation is that long-term outcomes have significantly improved over time with increased experience in these procedures. The objective of this study was to assess whether this is the case and to identify further areas of improvement. A total of 13,639 adult patients receiving an auto-HCT or allo-HCT for rrHL were reported to the European Society for Blood and Marrow Transplantation (EBMT) over a 25-year period. Regarding auto-HCT, recipients are younger, interval between diagnosis and transplant shorter, peripheral blood has become the universal stem cell source and the use of total body irradiation is almost non-existent in recent years. Allo-HCT is currently mostly used as a second transplant; recipients are younger, fitter and less frequently, chemorefractory. Reduced intensity conditioning protocols have vastly replaced myeloablative protocols. Increasing numbers of haplo-HCT have been reported. Both in auto-HCT and allo-HCT, NRM, PFS and OS have significantly improved but relapse remains the main cause of treatment failure. A better selection of patients and improvements in the supportive care has resulted in a reduction in the NRM. Relapse after HCT remains unchanged and further research is needed.

Introduction. Autoimmune diseases are a family of more than 100 heterogeneous conditions that affect 5 to 8% of the world’s population. The etiology is still un-known but the disregulation of the regulatory T-lymphocytes play a central role inthe autoimmunity and the success of the long-term remission. Although conventional immunosuppression and new biological agents can provide disease control in severely affected patients, such treatments are rarely curative and alternative strategies are needed. Indeed, severe forms of systemic autoimmune diseases, such as multiple sclerosis (MS), systemic sclerosis (SSc), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), juvenile idiopathic arthritis (JIA), hematologic immune cytopenia (HIC) and Crohn’s disease are difficult to be treated. High-dose immunosuppressive therapy followed by autologous stem cells transplantation is reliable option for a successive treatment of this group of patients. Aim. To determine the safety of the procedure of autologous stem cell transplantation in patients with autoimmune diseases and concomitant malignant hematological disorders. Methods. During a period of 15 years (from September 2000 to September 2015) at the University Clinic of Hematology in Skopje we have treated 6 patients with autoimmune disease and concomitant hematological neoplasm. None of the patients was treated for primary autoimmune diseases. Two men and 4 women, with median age of 47 years were treated. Sjogren syndrome and multiple myeloma were found in 2 patients, polyartheritis nodosa and multiple myeloma in 1 patient, rheumatoid arthritis and acute myeloblastic leukemia in 1, systemic lupus erythematosus and non-Hodgkin lymphoma in 1; severe psoriasis and acute myeloblastic leukemia in 1 patient. Results. All treated patients are alive after trans-planted procedure, with transplant related mortality day +100: 0. Conclusion. Autologous stem cell transplantation is safe and recommended option for treatment ofpatients with autoimmune disease and hematologic neoplasm.

Background. Peripheral blood stem cells (PBSC) have largely replaced conventional, unprimed bone marrow (BM) as source for autologous transplantation. Aim. To present the mobilizing strategies in patients with lymphoproliferative diseases taking in consideration demographic and treatment related variables that have influence as prognostic factors. Material and Methods. The study was accomplished with patients treated with autologous transplantation at University Hematology Hospital, Skopje, and Republic of Macedonia during 5 year period. A total of 70 patients with lymphoproliferative diseases were included in this study. Results. Patients transplanted with PBSC, compared with patients transplanted with BM showed p

Background. According to immunological deficit the period after hematopoietic stem cell transplantation (HSCT) can be divided in three phases: aplastic phase, phase of acute GVHD, and phase of chronic GVHD. Fungal infections are predominant in first, aplastic phase. Deep neutropenia and implantation of central venous catheter are two major risk factors contributing to infection. Aim. To retrospectively analyze fungal infections, fungal isolates and to compare success of different antifungal strategies during the first 30 days after HSCT. Material and methods. During a 7 year period (2000-2007), we have performed 128 HSCT in 120 patients with different hematological diseases. Male: 62 Female: 58. Median age: 34 years. Patients were treated in sterile room, conditioned with HEPA filters, and low microbes diet. Antifungal prophylaxis with Fluconazole 200mg, Itraconazole 200mg, or combination Fluconazole200/Itraconazole 200 (in high-risk patients) was administered from day 0 until day +100. Results. Patients treated with combination of Fluconazole200/Itraconazol200 have had only few oropharyngeal candidiasis, without signs of invasive fungal infection. There is no statistically significant difference between the prophylaxis with Fluconazole and Itraconazole, (p=0,302). Non-Albicans Candida is predominantly isolated funga (Non-Albicans Candida vs. Candida Albicans: 54% vs. 46%). There is no isolation of Aspergillus during the first phase after HSCT in our group of patients. Concluson. The rising incidence of invasive fungal infections and the currently problematic early diagnosis call for an intensive exploration of new drugs and further developments in diagnosis and treatment of invasive fungal infection.

e19502 Background: Autologous stem cell transplantation (ASCT) improves survival in patients with myeloma and lymphoma but is associated with morbidity and nonrelapse mortality (NRM). Hematopoietic cell transplant comorbidity index (HCT-CI) was shown to predict risk of NRM and survival after allogeneic transplantation. We tested the utility of HCT-CI as a predictor of NRM and overall survival (OS) in patients undergoing ASCT. Methods: We analyzed outcomes of 220 patients after high-dose melphalan and high –dose anti lymphoma chemotherapy during year 2000 to 2015. Individual comorbidities were prospectively collected at the time of ASCT. The impact of HCT-CI and other potential prognostic factors, including Karnofsky performance score (KPS), on NRM and survival were studied in multivariate Cox regression models. Results: HCT-CI score was 0, 1, 2, 3, and >3 in 42%, 18%, 13%, 13%, and 14% of the study cohort, respectively. Subjects were stratified into 3 risk groups: HCT-CI score of 0 (42%) versus HCT-CI score of 1 to 2 (32%) versus HCT-CI score > 2 (26%). Higher HCT-CI was associated with lower KPS < 90 (33% of subject’s score of 0 versus 50% in HCT-CI score > 2). HCT-CI score > 2 was associated with melphalan dose reduction (22% versus 10% in score 0 cohorts). One-year NRM was low at 2% (95% confidence interval, 1% to 4%). On multivariate analysis, overall survival was inferior in groups with HCT-CI score of 1 to 2 (relative risk, 1.37, [95% confidence interval, 1.01 to 1.87], P = .04) and HCT-CI score > 2 (relative risk, 1.5 [95% confidence interval, 1.09 to 2.08], P = .01). Factors that affect OS in the autologous recipients among lymphoma and myeloma patients were: HCT-CI, Karnofsky score, number of CD34+ cells/kg and time from diagnosis until transplant (p

8023Background: Considering the high prevalence of comorbidities in multiple myeloma (MM) patients, comorbidity has an important issue for the management of myeloma. However, the impact of comorbid...

Introduction. Allogeneic stem cell transplantation (allo-SCT) is a well established therapeutic alternative for those patients with refractory Hodgkin’s lymphoma (HL) who relapse after an autologous stem cell transplantation (ASCT), have chemosensitive disease and a HLA compatible donor available. The impact of the intensity of the conditioning regimen in the outcome of this procedure is still not well understood. An initial retrospective analysis from the European Group for Blood and Marrow Transplantation (EBMT) Lymphoma Working Party (LWP) (Sureda et al, JCO 2010) that compared myeloablative (MAC) with reduced intensity conditioning (RIC) protocols indicated that the high non-relapse mortality (NRM) associated to MAC-SCT translated into a non-significant improvement in progression free survival (PFS) for RIC recipients in spite of the higher relapse rate of the latter. As NRM for MAC-SCT might have decreased over time due to better patient selection, HLA typing and peri-transplant supportive measures, we hypothesize that overall results of more intensive protocols could compare better to RIC-SCT in recent years. Patients and Methods. We have included in this analysis adult patients with multiply relapsed classical HL treated with an allo-SCT between January 2006 and December 2010 and reported to the EBMT Database. Only first and second allo-SCT was included. Tandem ASCT-allo-SCT was excluded as well as cord blood transplantations and haplo-identical SCT. A total of 313 patients met the inclusion criteria (63 patients treated with a MAC and 250 patients treated with a RIC, definitions following the EBMT criteria). There were 173 males (55%) and 140 females (45%) with a mean age at diagnosis of 29 years and at SCT of 33 years. Mean time from diagnosis to SCT was of 43.3 months. 153 patients (49%) were chemorefractory at the time of allo-SCT and 166 patients (53%) had already failed a prior ASCT. Peripheral blood (PB) was used as the source of stem cells in 88% of the patients. Comparing MAC with RIC groups, the latter one was significantly older at allo-SCT (31 years vs 34 years, p=0.01), had a longer time interval between diagnosis and allo-SCT and preferentially received mobilized PB stem cells (82% vs 91%, p=0.01). There were also more prior autograft failures in the RIC group (56% vs 42%, p=0.006). Results. With a median follow up for alive patients of 32.5 (9.7 – 52.9) months, overall survival (OS) was 75% and 65%, PFS, 54% and 39%, NRM 11% and 12% and relapse rate after SCT of 37% at 1 year. There were no significant differences in NRM between MAC and RIC patients. Relapse rate was higher in the RIC group, although these differences did not reach statistical significance (55% vs 40% at 24 months, p=0.1). This lower relapse rate translated into an improvement in PFS for the MAC group (48% vs 37% at 24 months, p=0.08) with no differences in terms of OS (71% for MAC vs 61% for RIC at 24 months, p=0.4). Multivariate analysis after adjusting for disease status at the time of SCT showed that the use of RIC protocols was the only independent adverse prognostic factor associated to a higher relapse rate after SCT [HR 0.68, 95%CI (0.38 – 0.98), p=0.04] and to a lower PFS after the procedure [HR 0.65, 95%CI (0.43 – 0.98), p=0.04]. The intensity of the conditioning regimen did not have any impact n NRM in the multivariate analysis. Chemosensitive disease at SCT was the only independent prognostic factor for OS after SCT in the multivariate analysis [HR 1.70, 95%CI (1.17 – 2.46), p=0.005]. Conclusions. This retrospective analysis shows that NRM after MAC protocols is not a significant clinical issue when allografting patients with HL nowadays. On the other hand, using MAC decreases the relapse risk in this highly resistant population of patients, translating into a significant improvement of PFS. MAC protocols should be considered when designing prospective clinical trials in patients with HL candidates for an allogeneic stem cell procedure. Disclosures No relevant conflicts of interest to declare.

Nowadays, goal of treatment approach in diffuse large B cell lymphoma is cure and first step towards it is to achieve complete remission. DLBCL is a potentially curable disease, with curability highly dependent on clinical and biological features. According to the WHO classification of Hematological Malignancies, the entity of DLBCL is characterized by rapidly growing mature B cell tumors with large or relatively large cells and /includes a number of disease variants/entities / encompassing several distinct clinopathologic diseases, several different histologic variants and clinical subtypes. There is no unique treatment for all patients with diffuse large B cell lymphoma. Different subgroup of patients with DLBCL needs different treatment. In the pre-rutuximab era International Prognostic Index (IPI) was considered to be the most important prognostic factor for survival and the strongest indicator for identification of high-risk patients, who are unlikely to be cured with standard chemotherapy. Having in mind that IPI is based on 5 clinical characteristics (age, performance status, stage, extranodal involvement, LDH level) and it is constructed in the pre-rituximab is clear that R-IPI should be tested in rituximab era to provide any information of its validity. We retrospectively analyzed unselected population of 80 patients with confirmed diagnose of diffuse large B cell lymphoma treated at University hematology department in the period of 2005-2010. All patients were uniformly treated with R-CHOP regiment as initial treatment with curative intent. There were 80 patients with mean age 54, 5 years (15-84), male 35 and female 45. Older than 60 years were 29 patients (36, 25%). More than half of the patients (42) were diagnosed in advanced stage of the disease. We analyzed five prognostic factors: age, performance status, stage, extranodal involvement, LDH level and through the multifactorial analyses we selected two groups of patients. One with 0 to 2 factors as patients with low risk. Patients with more than 3 factors are considered as high risk. There is statistically significant difference in overall survival between two groups with five –years overall survival 70% for low risk patients and 47% for high risk. High-risk patients may be candidates for autologous transplantation as initial treatment, having in mind that in the rituximab era relapses occur very early in the first year and are difficult to be treated. R-IPI score is significant predictor and should be used for risk stratification of patients with aggressive B-cell lymphoma. However, these findings should be validated prospectively in an independent population of patients. Disclosures: No relevant conflicts of interest to declare.

Abstract 4595 Despite advances in our understanding of its pathogenesis, acute myeloblastic leukemia remains difficult to treat. Although initial complete remission can be achieved in a high percentage of patients, relapse occurs in 70–80% of the patients. Two main approaches have been the attempt to eradicate the leukemic clonal cells population via chemotherapy with or without autologous stem cell rescue or to pursue a combined approach using an antileukemic therapy combined with an antileukemic immune response via allogeneic bone marrow transplantation. Autologous transplantation compares favorably against allogeneic bone marrow transplant in several ways. Autologous transplantation can be used as a consolidation therapy in the older population, and lack of a matched donor does not preclude the patients from this treatment. We report a retrospective analysis on 48 patients diagnosed with de novo AML, who did not have an available histocompatible donor, and who underwent autologous transplantation between years 2000–2009 at the University hematology Clinic, Skopje, Macedonia. All patients had ECOG score 1 or less. The patient's age ranged from 17 to 65 years with the median age 41 years. There were 26 males and 22 females. For stem cell mobilization patients received chemotherapy or chemotherapy plus G-CSF. The preparative chemotherapy regimen prior to autologous transplantation consisted of BuCy in 24 patient, BEAM in 22 and BuCyMel was used in the remaining 2 patients. We used bone marrow as primary source of stem cells in 18 patients, and peripheral blood stem cells in remaining 30 patients. The five years overall survival was 52% and the 5 years disease progression free survival were 42%. We analyzed sever factors that can influence the overall survival and the disease free survival such as: age, disease status, stem cell source, chemotherapy regiments prior to transplantation, conditioning regiments, number of mobilized stem cells. Advanced age and bone marrow stem cell source seems to be more influent factors. We report that the clinical results of autologous hematopoietic stem cell transplantation are sufficiently encouraging to warrant future trials that include autologous transplantation as an option for appropriately selected patients with AML in CR1. We conclude that autologous hematopoietic stem cell transplantation is a reasonable and save intensive consolidation for patients with acute myeloblastic leukemia who do not have a suitable HLA–matched donor. Disclosures: No relevant conflicts of interest to declare.

Lymphocyte-predominant Hodgkin disease (LPHD) presents as early-stage disease with slow disease progression and excellent initial response to conventional chemotherapy. Although 96% of LPHD patients experience a complete remission (CR) upon first line treatment, many relapses occur. Residual tumor cells in Hodgkin’s patients can survive standard therapy and cause relapse. Thus, the elimination of minimal residual disease after first line treatment might improve the outcome in Hodgkin disease. CD20+ is strongly expressed by malignant cells in LPHD, but so far there is limited information regarding the efficacy of Rituximab in this patient population. A 66 year-old woman presented with bilateral inguinal lymphadenopathy in 2004 and complained on malaise and weight loss. Lymph node biopsy confirmed a diagnosis of LPHD and immunohistochemistry confirmed that CD20 antigen was expressed on more than 30% of malignant cells. Staging revealed II B disease. There were lymph node enlargements in the pelvis on CT. Her blood count, erythrocyte sedimentation rate, and albumin were normal with elevation of and lactate dehydrogenase and alkaline phoshatase. She was treated with ABVD regiment 8 cycles and CR was achieved. After standard chemotherapy patient with CD20+ LPHD received four weekly doses of Rituximab at 375 mg/m2 and maintenance therapy with additional four doses of Rituximab every three months for the next year. Treatment was well tolerated without any complications. Evaluation of disease assessment included physical examination and computed tomography, bone marrow biopsy and routine analyses, after the end of treatment and every 3 months after for the first two years, and on six months for the following year. There were no abnormalities on CT after the end of the treatment. Patient was in complete remission. CT after 36 months showed no detectible tumor mass. Patient remains still in complete remission three years after chemotherapy without detectible tumor mass. Our case report suggests that Rituximab is both safe and effective in patients with CD20+ LPHD. The optimal treatment for patients with LPHD remains uncertain. Current research aims to identify alternative treatment approaches that possess significant activity but less toxicity. Radiotherapy for early-stage patients and chemotherapy or combined modality treatment for advanced-stage patients remains to be standard of care. Initial observed benefit of Rituximab treatment in this group of patients suggests that there is a role for monoclonal antibodies in optimal treatment approach, especially in improving the outcome. Further studies with Rituximab are warranted in this patient population.

Patients with lymphocyte-predominant Hodgkin disease (LPHD) often present at an early stage with slow disease progression. Although 96% of LPHD patients experience a complete remission (CR) upon first line treatment, many relapses occur. CD20+ is strongly expressed by malignant cells in LPHD, but so far there is limited information regarding the efficacy of rituximab in this patient population. We report 46-year-old woman who presented in 2004 with left cervical lymphadenopathy and weight loss. Case report: Biopsy confirmed a diagnosis of LPHD(stage IIB disease), immunohistochemistry revealed that >30% of malignant cells were CD20+, and a bulky mediastinal mass was observed by computer tomography (CT). Blood counts, erythrocyte sedimentation rate, albumin and lactate dehydrogenate were normal. The patient was treated with rituximab and ABVD (doxorubicin 25mg/m2, bleomycin 10mg/m2, vinbalstine 6mg/m2, dacarbazine 375mg/m2, six cycles). Rituximab was administered (375mg/m2) one day before chemotherapy (50mg/h for one hour and gradually escalated to a maximum of 400mg/h). Treatment was well tolerated and there were no complications. The patient was assessed immediately following treatment and every three months for the following year, by physical examination, CT, bone marrow biopsy and routine analyses. A detectable tumor mass was no observed by CT for the follow up of 2 years, the patient remains in complete remission. Conclusion: Our case report suggests that Rituximab is both safe and effective in patients with CD20+ LPHD. Further studies with Rituximab are warranted in this patient population.

There are two subgroups of the untreated lymphomas according to the outcome of the disease: indolent and aggressive. Unlike the indolent lymphoma, aggressive lymphomas are fatal in several weeks or months if untreated. However, the therapy available nowadays makes this group of patients with aggressive Non-Hodgkin’s lymphoma curable. Autologous stem cell transplantation used as first-line therapy can improve overall survival in selected group of patients with aggressive Non-Hodgkin lymphoma. To make the right and optimal therapeutic approach we need to stratify those patients in subgroups of patients with "high" and "low" risk, which was achieved with this study. This study comprises 211 patients with histopathology diagnosis of aggressive Non-Hodgkin’s lymphoma treated at the Department of Hematology in the period 1989–2002, which gave us the observation period of 6 to 183 months. There were 88 male patients, median age 53 years and 60 female, median age 52 years. Most of the patients were in the advanced clinical stage at the disease on the initial presentation of the disease, 24% of the patients in the third stage and 43% in the fourth stage. Bone marrow infiltration was found in 29%. Bcl-2 positively was confirmed in 26 cases by imunohistochemistry and there was proliferative index Ki-67 above 60% in 32 patients. Imunophenotipisation suggested that 80% of the cases are B-cell lymphoma. The patients were treated with antracicilin included regiments, most of them being CHOP regiment. After initial chemotherapy complete remission was achieved in 60%, partial response in 4% and there was no response in 32% with early deaths in 4%. At the end of the study 32% of the patients were alive and well, 32% were deceased and the reminder had unknown status. There was relapse of the disease in 50 patients with previous complete remission. According to the univariante analysis the following parameters had significantly influence the overall survival in the patients with aggressive Non-Hodgkin’s lymphoma: initial anemia, initial LDH, the stage of the disease, ECOG score, bone marrow infiltration, number of sites of extranodal infiltration, lymphoma subgroup according to various classification systems, morphology of the lymphoma cell, imunophenotype profile, percent of Ki-67 positively, bcl-2 positively, time to complete remission. The multiply progression analysis produce mathematical model through which we can anticipate the expected survival in each patients individually based on the statistically most influential prognostic markers, those achieving stratification of the patients in risk groups. In our study 32% of the patients with "high" risk are alive and "low risk patients have 70% 5-years overall survival. With the use of this prognostic model for aggressive Non-Hodgkin’s lymphoma we achieved risk based stratification of the patients even in the fourth stage of the disease with statistical significance. This prognostic model for aggressive Non-Hodgkin’s lymphoma enables the clinical hematologist to create the optimal individual therapeutic approach for each patient with aggressive Non-Hodgkin’s lymphoma. The patients with "high" risk are group of patients where beside the standard chemotherapy, use of aggressive chemotherapy and haematopoetic stem cell transplantation as well as the new therapeutic approaches would improve therapeutic results and overall survival.